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125 Cards in this Set

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What is your approach to reading chest x-rays?
Out to in:

1) Humeri -- clavicles -- scapulae -- ribs -- spine

2) Pleural margins (look for PTX, nodularity, thickening, mass, or small effusion)


3) Airways


4) Mediastinum
What areas of the mediastinum do you have to look at?
1) Paratracheal stripe


2) AP window


3) Azygoesophageal recess


4) Paraspinal lines


5) Junction lines
What specific structure in the airways must you look at?
Posterior wall of bronchus intermedius
What is the next thing you look at?
Hilar shadows
Then?
Cardiac silhouette
Then?
Pulmonary parenchyma
What about pulm parenchyma?
1) Lung volumes


2) Difference in density between left and right lung


3) Focal or diffuse lung abnormalities
What is approach to reading an ICU film?
1) Look at position of lines and tubes



2) Look for pneumothorax or pneumomediastinum


3) Look for focal parenchymal opacities


4) Look for diffuse parenchymal opacities
What is DDx for focal parenchymal opacities?
1) Atelectasis


2) Pneumonia


3) Aspiration


4) Contusion


5) Hemorrhage
What is DDx for diffuse opacities in ICU patient?
1) Edema


2) Pneumonia


3) ARDS


4) Hemorrhage
When encountering an apparently normal CXR, what is the first thing to look at?
Bones
For what?
1) Rib notching


2) Lytic or sclerotic lesions
What is the second area to look at?
Mediastinum
For what?
1) Posterior mediastinal mass


2) Subtle hilar mass lesion
What next?
Airway
For what?
1) Tracheal mass/stenotic lesion


2) Airway deviation


3) Carinal splaying
What is the next area to look at?
Lungs
For what?
1) Retrocardiac disease


2) Hidden nodules


3) Bronchiectasis


4) Subtle interstitial disease


5) Overall differences in lung density


6) Evidence of PE
What are signs of right upper lobe collapse?
Elevation of minor fissure


Rightward shift of trachea


Elevation of right hilum
What does RUL collapse look like when complete?
Thickening of right paratracheal stripe
What are causes of recurrent right middle lobe atelectasis?
Bronchus surrounded by enlarged lymph nodes
What is appearance of RLL collapse?
Triangular opacity in right retrocardiac region, with obliteration of diaphragm


Opacity over the spine
LUL collapse?
Difficult to see: Just see hazy density, which can easily be confused with loculated pleural effusion
What is a sign seen in LUL collapse?
Luftsichel
What is luftsichel?
On PA view, you see an area of lucency surrounded by increased density, which represents the superior segment of the left lower lobe rising up higher now that the left upper lobe is collapsed.
What does the lateral view look like in LUL collapse?
The left lower lobe is anterior; thus when it collapses, the minor fissure gets pulled anteriorly with it.
What is appearance of LLL collapse?
Left retrocardiac opacity


On lat view, posterior displacement of the major fissue
What causes lung consolidation?
Confluence of acinar shadows
What specifically?
Fluid, inflammatory exudate, or tissue in acini
What types of fluid?
Water


Blood


Proteinaceous fluid
What causes water in acini?
Pulmonary edema
What causes blood in acini?
Trauma is most common cause
What are other causes?
Bleeding disorder or anticoag


Pulmonary infarct


Vasculitis, including Goodpastures and Henoch-Schonlein
What causes proteinaceous fluid?
Alveolar proteinosis
What are general causes of inflammatory exudate in acini?
Infection and non-infectious inflammation
What are noninfectious causes?
Allergic hypersensitivity pneumonitis


Chronic eosinophilic pneumonia


BOOP


Loeffler's syndrome


ABPA


Aspiration of lipid material


Sarcoidosis
What causes soft tissue in acini?
Tumor
Which tumors?
Bronchioloalveolar CA


Lymphoma
What is first step in evaluating solitary pulm nodule?
Assess age and smoking status
What is the age cutoff?
30
What if patient is under 30 and non-smoker?
Stop or follow up imaging
What is the first question to ask if patient is a smoker or is over 30?
Are there any prior films
What is the question to ask on the prior films?
Has the lesion enlarged
What if there is no interval change?
Assuming this is a good interval, you can do follow-up imaging or stop
What if the lesion is enlarging?
Biopsy it
What if there are no prior films available?
Do thin section CT through lesion
What are you looking for on thin section CT?
Calcification or fat
What if there is no calcification or fat?
Biopsy it, either percutaneously or via bronch
What if there is fat?
Presumed hamartoma, and you can stop
What if there is calcification?
Must assess what type of calcification
What types of calcification suggest benign lesion?
Diffuse


Popcorn


Concentric (lamellar)


Single central
What types of calcification are indeterminate?
Stippled


Single eccentric
What characteristics of a solitary pulmonary nodule need to be assessed?
Shape


Size


Presence of spiculations


Edge (Zone of transition)


Satellite lesions


Cavitation


Doubling time
What do satellite lesions suggest?
Benignity
What does cavitation suggest?
Malignancy
What doubling time suggests benignity?
Less than one month


OR


Greater than 2 years
How many criteria are there that can reliably be used to assess a solitary pulmonary nodule as benign?
Only 3
What are they?
1) Presence of fat



2) Benign types of calcificaton



3) No interval growth for 2 years
What HU is needed to call lesion calcified?
200 HU
What percent of the lesion must be calcified before you can even assess the type of calcification?
10%
What is the exception to the calcification rule?
Osteosarcoma and thyroid mets can calcify. However, they will be seen in multiplicity. Only consider this if patient has history of one of these diseases.
What are most solitary pulmonary nodules?
Granuloma or primary carcinoma
What are the rest?
Some are AVMs, and the possibility of this should be assessed before biopsy
Where are most pulmonary nodules missed?
1) Lung apices


2) Central and paramediastinal lungs


3) Superimposed onto ribs and clavicle
What is the differential for solitary pulmonary nodule?
Tumor


Inflammation


Other
What percent are inflammation?
53%
What types of inflammation?
Granuloma from Tb, histo, or coccy
What percent are tumor?
45%
What types of tumor?
Primary CA


Solitary met


Hamartoma
What percent of solitary lung tumors will be primary CA?
70%
What percent of solitary lung tumors will be solitary met?
10%
What percent of solitary lung tumors will be hamartoma?
15%
What are the other 2% of solitary pulmonary nodules
Vascular lesions


Congenital lesions


Miscellaneous lesions
What are the vascular lesions that present as nodules?
AVM


Pulmonary varix
What are the congenital lesions that present as nodules?
Sequestration



Bronchial cyst
What are the miscellaneous causes of solitary nodule?
Round pneumonia


Loculated effusion in fissure (pseudotumor)


Mucous plug


Enlarged subpleural node


Silicosis (rare)
What are causes of multiple pulm nodules?
Mets


Abscess


Granulomatous lung disease
What varieties of granulomatous lung disease cause multiple pulmonary nodules?
Infectious and noninfectious
What are the infectious causes of granulomatous lung disease?
Tb


Fungus
What are the noninfectious causes?
Sarcoid


Silicosis


Wegener's


Rheumatoid nodules
What if the nodules are small, bilateral, and very numerous?
Consistent with miliary dz, which has a differential
What are the causes of miliary pattern?
Tb


Certain mets
What are the mets that can do miliary pattern?
Thyroid



Melanoma


Breast


Choriocarcinoma
What if the nodules are very small?
Consistent with nodular interstitial disease
What is differential for calcified lung nodules?
Depends on average size of nodules.
What if nodules are 1 mm or more on average?
Tumor


Infection


Silicosis
What tumors calcify?
Mets
Which mets?
Thyroid CA


Osteosarcoma


Mucinous carcinomas
What are infectious causes of calcified lung nodules?
Tb/histo/coccie


Varicella


Schistosomiasis
What about calcified nodules that are very small (on average less than 1 mm?)
Metastatic calcification, usually from chronic renal disease



Chronic pulmonary venous hypertension



Alveolar microlithiasis
What is ddx for a large pulmonary parenchymal mass (>6cm)?
Tumor (primary or metastatic)


Abscess


Round atelectasis (associated with effusion)


Intralobar sequestration


Bronchogenic cyst


Hydatid disease
What metastatic lesions tend to give big lung mets?
SCC from head/neck
What is ddx for a large extrapulmonary mass?
Loculated pleural effusion


Fibrous tumor of pleura


Chest wall tumors


Mediastinal masses
When you have a cystic/cavitary intraparenchymal lesion, what is most helpful (but not always) to determine if benign or malignant?
Wall thickness
What are criteria?
Wall < 2mm thick



Wall 2-15 mm thick


Wall > 15 mm thick
What percent of <2mm are benign?
95%
What percent of 2-15 are benign?
50%
What percent of >15mm are benign?
<5%
When the wall is thick, what are you dealing with?
cyst
What is the differential diagnosis for cyst?
1) Pneumatocele


2) Bulla/bleb


3) Cystic bronchiectasis


4) Congenital cysts


5) Hydatid cyst
What causes pneumatocele?
Infection or trauma
What is the difference between a bulla and a bleb?
Bulla is intraparenchymal


Bleb is in the pleura
What types of congenital cysts are there?
1) Bronchogenic cysts


2) Cystic adenomatoid malformation


3) Sequestration can have cystic elements
What is the differential diagnosis for a lung cavity (i.e. thick walls)
1) Abscess


2) Cavitated tumor


3) Cavitated granulomatous mass


4) Cavitated hematoma
What are tumors that can cavitate in the lung?
1) SCC (lung or metastatic)



2) Sarcomas



3) TCC of bladder



4) Lymphoma
What is true of cavitated granulomatous masses?
Usually multiple
What are the causes of cavitated granulomatous mass?
Tb


Sarcoid


Wegener's


Rheumatoid


Fungus (aspergillus)
What entities can have an air crescent sign?
1) Invasive aspergillosis


2) Septic emboli


3) Mucor


4) Tb


5) Tumors
How do you analyze small cystic disease of the lung?
Determine whether the cysts have a true wall or no wall.
What is the diagnosis of small cystic disease with no cyst wall?
Emphysema
What is the differential for small cystic disease with true walls?
1) Honeycombing in any end-stage interstitial disease



2) Cystic form of PCP



3) LAM



4) Eosinophilic granuloma
What is the approach to interstitial disease? First
1) Type of pattern
Second?
Distribution
3rd?
Lung volumes
4th?
Lymph nodes
5th?
Pleural disease
6th?
Evolution of disease
What is the categorical differential for proximal intraluminal airway mass?
Tumor


Inflammatory disease


Foreign body


Mucus plug



Broncholith
What percent of upper airway masses are due to tumor?
80%
What percent of upper airway tumors are benign?
25%
What is the differential for benign tumors?
Hamartoma



Papilloma



Hemangioma



Pleomorphic adenoma
What is the differential for malignant tumors?
SCC (most common tumor)


Adenoid cystic carcinoma (next most common)


Mucoepidermoid


Carcinoid
What percent of upper airway endobronchial tumors are metastatic lesions?
5%
What tumors tend to invade the trachea from outside?
Thyroid


Lung


Esophageal
What is clinical scenario that goes with airway mass?
Patient undergoing workup for intractable asthma-like symptoms